Supercapsular percutaneously assisted total hip approach combined with local and intravenous tranexamic acid reduces perioperative hidden blood loss in hemiarthroplasty

Abstract

BACKGROUND: Intraoperative blood loss in hip hemiarthroplasty is reduced with the supercapsular percutaneously assisted total hip approach compared with the posterolateral approach, but the difference in hidden blood loss between the two approaches and the effect of tranexamic acid on it has not been fully investigated. OBJECTIVE: To investigate whether the supercapsular percutaneously assisted total hip approach reduces perioperative hidden blood loss in hip hemiarthroplasty for unstable femoral neck fractures in advanced age compared with the posterolateral approach and to analyze the effect of combined local and intravenous tranexamic acid on it. METHODS: This study retrospectively analyzed a total of 200 elderly unstable femoral neck fracture patients who underwent hip hemiarthroplasty in the Department of Orthopedics, First Affiliated Hospital, Soochow University from January 1, 2020 to December 31, 2024. They were divided into four groups (n=50 per group) according to the surgical approach and whether tranexamic acid was used in the perioperative period: (1) posterolateral approach group; (2) posterolateral approach + tranexamic acid group (combined local and intravenous tranexamic acid); (3) supercapsular percutaneously assisted total hip approach group; (4) supercapsular percutaneously assisted total hip approach + tranexamic acid group (combined local and intravenous tranexamic acid). General data including age, sex, height, weight, and surgical side, as well as preoperative hemoglobin, hematocrit, prothrombin time, activated partial thromboplastin time, and fibrinogen were collected. Hemoglobin and hematocrit were measured on postoperative day 3, and total blood loss and hidden blood loss were calculated. RESULTS AND CONCLUSION: (1) There were no statistically significant differences in preoperative general data among the four groups. (2) The total blood loss and hidden blood loss on postoperative day 3 in the supercapsular percutaneously assisted total hip approach group were significantly lower than those in the posterolateral approach group (P < 0.05). (3) The total blood loss and hidden blood loss in the posterolateral approach + tranexamic acid group were significantly lower than those in the posterolateral approach group without tranexamic acid (P < 0.05). (4) The total blood loss and hidden blood loss in the supercapsular percutaneously assisted total hip approach + tranexamic acid group were significantly lower than those in the supercapsular percutaneously assisted total hip approach group without tranexamic acid (P < 0.05). (5) The incidence of lower extremity venous thrombosis was very low in all groups, with no statistically significant difference among groups. (6) These findings suggest that compared with the traditional posterolateral approach, the supercapsular percutaneously assisted total hip approach for hip hemiarthroplasty in elderly patients with unstable femoral neck fractures can reduce perioperative total blood loss and hidden blood loss; combined local and intravenous tranexamic acid can reduce perioperative blood loss in both traditional and supercapsular percutaneously assisted total hip approaches without increasing the risk of thrombosis.

1. Introduction

Currently, for elderly femoral neck fractures, especially unstable types (Garden type III or IV), hip hemiarthroplasty (hemiarthroplasty) has become the preferred method [1-6]. However, traditional surgical approaches for hemiarthroplasty have their own disadvantages, especially a large amount of hidden blood loss, which often leads to postoperative anemia, increased transfusion rates, relatively longer recovery time, and increased long-term mortality [7]. Hidden blood loss typically occurs in major surgical procedures and is defined as the blood loss discovered by subtracting visible blood loss from total blood loss [8]. Studies have found that hidden blood loss accounts for a large proportion of total blood loss in hip arthroplasty [9].

In 2011, CHOW et al. [10] first reported the supercapsular percutaneously assisted total hip approach (SuperPATH), which combines the percutaneous tube technique for acetabular preparation via the PATH approach and the in-situ femoral preparation via the SuperCap approach. It enters the hip joint capsule through the interval between the gluteus medius/piriformis and gluteus minimus, without cutting muscles, thereby maximizing protection of the capsule and other soft tissues around the hip, truly meeting the criteria of minimally invasive surgery [11]. Numerous studies have shown that the SuperPATH technique has several advantages, such as low complication rates, satisfactory radiological outcomes, shortened hospital stay, and good early functional recovery [12-13]. A recent meta-analysis indicated that patients over 70 years old are more likely to benefit from SuperPATH hemiarthroplasty, and thus it is recommended to widely consider minimally invasive SuperPATH hemiarthroplasty in elderly patients [14]. However, studies on whether SuperPATH can reduce perioperative total and hidden blood loss in hemiarthroplasty have yielded inconsistent results [15-18].

Tranexamic acid is a synthetic lysine amino acid derivative and is one of the most commonly used hemostatic agents, reducing fibrinolytic activity by lowering plasma plasminogen levels [19]. Clinical work and studies have found that combined local and intravenous use of tranexamic acid can reduce hidden blood loss in hip arthroplasty [20-21]. Although the specific mechanism is not fully understood, it is known that this effect is related not only to reduced fibrinolytic activity but also to its anti-inflammatory effects [22]. Although tranexamic acid has been proven to reduce blood loss in orthopedic surgeries and is safe regarding coagulation-related complications, its specific local and intravenous application regimen and actual clinical efficacy in SuperPATH hemiarthroplasty have not been reported.